EVALUATION OF CERVICAL SPINE INJURY

SRI SIDDHARTHA MEDICAL COLLEGE,TUMKURDEPARTMENT OF ORTHOPAEDICSTOPIC:The effect of intact fibula on functional outcome of reamed intramedullary interlocking nail in open and closed isolated tibial shaft fractures: A prospective study

Chairperson & Moderator :prof. & HOD Dr.Mahesh K.UDept. of OrthopaedicsPresenter:Dr. Jaipalsinh MahidaDept. of Orthopaedics

INTRODUCTIONTibia is main weight-bearing bone in the leg, carrying greater than 80% of load. Tibia and fibula Fractures relatively common and have been recognized as serious and debilitating injuries for centuries.The management is influenced greatly by the associated soft tissue injury.Severe open fractures of the tibia are associated with high complication rates and poor long term outcomes. Tibial fractures have relatively high rates of nonunion and malunion Compared to fractures elsewhere in the body

Isolated tibial shaft fractures with intact fibula are a fairly common injury. have been associated with nonunion rates ranging from 1% to 17%. Primary fibulectomy has been recommended in order to overcome the adverse effect of an intact fibula accepting the additional morbidity associated with this procedure. The intact fibula is often blamed for problems related to union in these fractures. The primary aim of the study whether these fractures can unite without a primary fibulectomy.

ANATOMYLower leg contains 2 bones1. TibiaTriangular in shapeThick cortex & strongDistal articular surface is externally rotated approx. 200 compared to proximal articular surface. (tibial torsion).Distal articular surface is perpendicular to the mechanical axis of the tibia, whereas the proximal articular surface is tilted slightly medial.2. Fibulalies posterior and lateral to the tibia Both bones are connected by a thick interosseus membrane

Tibia has medullary and a periosteal blood supply. Outer 25% to 30% of cortex derives its oxygenation primarily from the periosteal system, Rest of the bone is predominantly supplied by the medullary system.Main nutrient artery to the tibia is branch of the posterior tibial artery and enters the bone in its proximal one-third. Reaming has been shown to temporarily decrease medullary blood supply in animal studies.However, animal studies have also shown that loss of the medullary arterial system results in stimulation of the periosteal system and reversal of the normal direction of blood flow through the anastomoses between the two vascular systems.

Compartments and Musculature:The musculature of the leg is divided into four compartments.

The Four Compartments of the Leg with the Muscles, Arteries, and Nerves Contained Within ThemCompartmentMusclesArteries & nervesAnteriorTibialis anterior

Extensor hallucis longus

Extensor digitorum longus

Peroneus tertius Anterior tibial arteryDeep peroneal nerveLateralPeroneus longus

Peroneus brevisSuperficial peroneal nerve Superficial

posteriorGastrocnemius

Soleus

Plantaris

Deep posteriorTibialis posterior

Flexor hallueis longus

Flexor digitorum longus

PopliteusPosterior tibial artery

Peroneal artery Tibial nerve

The anterior compartment musculature originates predominantly from the anterolateral aspect of the proximal tibia and includes the main dorsiflexors of the ankle and toes.

The lateral compartment muscles evert the foot and take origin from the lateral and posterior aspects of the fibula diaphysis. The lateral compartment also contains the superficial peroneal nerve which exits the fascia approximately 10 to 12cm proximal to the tip of the distal fibula. The superficial Peroneal nerve is at risk during lateral fasciotomy, distal fibular fixation, and placement of distal screws during percutaneous plating of the tibia.

The superficial posterior compartment are Primary ankle plantarflexor, and the plantaris muscle.

The posterior deep compartment is bordered anteriorly by the posterior surface of the tibia and the interosseus membrane. It contains tibialis posterior which inverts the foot, flexor hallucis longus and flexor digitorum longus, which plantarflex the toes, in addition to popliteus, and the peroneal artery, posterior tibial artery, and tibial nerve.

The posterior deep compartment can be difficult to assess for compartment syndrome by clinical examination and it is the compartment most often incompletely released during fasciotomy.

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The anterior compartment musculature originates predominantly from the anterolateral aspect of the proximal tibia and includes the main dorsiflexors of the ankle and toes.

The lateral compartment muscles evert the foot and take origin from the lateral and posterior aspects of the fibula diaphysis. The lateral compartment also contains the superficial peroneal nerve which exits the fascia approximately 10 to 12cm proximal to the tip of the distal fibula. The superficial Peroneal nerve is at risk during lateral fasciotomy, distal fibular fixation, and placement of distal screws during percutaneous plating of the tibia.

The superficial posterior compartment are Primary ankle plantarflexor, and the plantaris muscle.

The posterior deep compartment is bordered anteriorly by the posterior surface of the tibia and the interosseus membrane. It contains tibialis posterior which inverts the foot, flexor hallucis longus and flexor digitorum longus, which plantarflex the toes, in addition to popliteus, and the peroneal artery, posterior tibial artery, and tibial nerve.

The posterior deep compartment can be difficult to assess for compartment syndrome by clinical examination and it is the compartment most often incompletely released during fasciotomy.

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Mechanisms of Injury:

Tibial fractures have a bimodal distribution with low-energy spiral patterns more common in patients over 50 years most common causes falls from a standing height and sporting injuries.high-energy transverse and comminuted fracturesmore common in patients under 30 years of age. most commonly associated with vehicular trauma.

Because of its subcutaneous location open fractures of the tibia are common with reported rates varying between 12% and 47% Open fractures are even more common with high-energy mechanisms with rates as high as 63% being reported following motorcycle crashes. When open fractures occur in the tibia they are more commonly type IIIB requiring flap coverage.

CLINICAL EVALUATIONSigns & Symptoms: PainInability to walk or bear weight on the legDeformity or instability of the legBone "tenting" the skin or protruding through a break in the skinOn physical examination focus on:Compromised SkinWoundsVascularMotorSensory

Evaluation of compartment syndrome: pain out of proportion to injury severity, pain on passive stretch of the relevant compartment musculature, paresthesiae, paralysis of the muscles in the affected compartments, severely swollen or indurated compartments, and in rare cases, pulselessness.

Imaging & Diagnostic studies: Radiographic evaluation (full length tibia with knee and ankle joint)Anteroposterior viewLateral view

Computed tomography ordered to exclude commonly associated fractures near joints.

The management of tibia diaphyseal fractures is influenced most significantly by the state of the soft tissues. Therefore, in clinical practice tibial fracture classification is meaningless without a classification of the associated soft tissue injury.Classification:

The Tscherne classification is used to classify closed fractures.

C0 - simple fracture configuration with little or no soft tissue injury.C1 Superficial abrasion, mild to moderately severe fracture configuration.C2 deep contamination with local skin or muscle contusion, moderately severe fracture configuration. C3 extensive contusion or crushing of skin or destruction of muscle, severe fracture.

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The Gustilo - Anderson classification used to classify open fractures.

TYPE I - Clean wound of less than 1 cm in lengthTYPE II - Wound larger than 1 cm in length without extensive soft tissue damageTYPE III - Wound associated with extensive soft tissue damage; usually longer than 5cmTYPE IIIA - Adequate periosteal cover TYPE IIIB - Presence of significant periosteal strippingTYPE IIIC - Vascular repair required to revascularize leg

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The most commonly used classification system for fractures of the tibia and fibula is the AO/OTA classification which separates fractures into Type A - simple fractures,Type B - wedge fractures, and Type C - complex fractures

Treatment Options:

Nonoperative Treatment:Multiple studies have demonstrated that nonoperative management is associated with poorer results when compared to IM nails with reference to nonunion, malunion, return to work, outcome scores, or time to union. Despite this there is still a role for nonoperative management in treating adults with tibial diaphyseal fractures. Displaced tibial fractures without a fibular fracture are prone to fall into varus with nonoperative treatment, Require particular caution and close monitoring when treated closed.

The Indications and Relative Contraindications for Nonoperative ManagementIndicationsRelative ContraindicationAdequate alignment, length, and rotation in a splint or castSignificant anesthetic riskPatient refuses operative treatmentInadequate alignment, length, and rotation after application of splint or castOpen fractureArterial injuryDisplaced proximal or distal fractureCompartment syndrome or high risk of compartment syndromeSoft tissues will not tolerate a splint, cast, or bracePatient unable to comply with nonoperative protocolIpsilateral femoral diaphyseal fractureHigh-energy mechanism or soft tissue injury

Acceptable Malalignment in Tibial Diaphyseal FracturesAlignment ParameterAcceptable MalalignmentVarus

Valgus

Apex anterior/ posterior

Rotation

Shortening